Repeating hemostatic clip applying instruments and multi-clip cartridges therefor

ABSTRACT

A cartridge for use with a repeating hemostatic clip applying instrument. The instrument is generally shaped and operated in the manner of prior clip applying instruments. Shaped like a pair of dog-nosed pliers, the outer ends of the jaws are adapted to hold a clip which may be applied to a blood vessel with the instrument. The rearward portion of the jaws overlap and a rectangular channel is formed in one of them through which clips may be pushed by a pusher extending down the center line of the instrument. One of the jaws is adapted to receive a cartridge containing a stack of U-shaped clips which may be pushed one at a time to the distal end of the jaws by the pusher. 
     The cartridge is provided with a spring for urging the U-shaped stack of clips down to the pusher channel, and a clip follower for preventing misalignment of the clips in the cartridge.

RELATED APPLICATIONS

This application is a Continuation-in-part of my United StatedApplication, Ser. No. 730,933, filed Oct. 8, 1976, entitled "REPEATINGHEMOSTATIC CLIP APPLYING INSTRUMENTS AND MULTI-CLIP CARTRIDGESTHEREFOR", now U.S. Pat. No. 4,166,466.

SUMMARY OF THE INVENTION

This invention relates to repeating hemostatic clip applying instrumentsand multi-clip cartridges therefor. More particularly, it relates to therapid and repeated ligation of so called bleeders in surgicalprocedures.

After a surgeon has made his incision, it is necessary to clamp thetissue wherever blood is being lost due to the cutting of blood vessels.The usual technique is to clamp each so-called bleeder with a hemostat(locking dog-nosed pliers) as soon after the vessel is severed aspossible. This controls the loss of blood until a ligature can be tiedaround the vessel. As many as 20 or more bleeders may be clamped by asmany hemostats in common surgical procedures before they are tied. Thus,a single operation often requires the use of a large number ofhemostats. These are handed to the surgeon and his assistants, one at atime, by the scrub nurse.

The surgical field often becomes cluttered with hemostates, whichinterfere with the surgeon's view and hinder the convenient applicationof additional hemostats. However, a good surgical practice requires theapplication of hemostats to all bleeders before they are tied.

The tying process requires one hand to hold the hemostat and two handsto pass the suture material around the hemostat and to form the ligatureby tying a knot. This procedure thus requires two people. In addition,the ligatures must be cut and the excess suture material removed fromthe incision. The used hemostats must be handed to the scrub nurse andbe readied for reuse. Thus, this entire technique for the achievement ofhemostasis requires the coordination and teamwork of at least threepeople. The speed with which the bleeders may be tied off is often thedetermining factor in the time required for the opening stages of manysurgical operations.

Many instruments have been disclosed in the prior art for ligatingbleeders. However, none of these have come into general use, due toinherent deficiencies. Instruments such as disclosed in U.S. Pat. Nos.3,033,204, 3,040,747, and 3,169,526, issued to E. C. Wood; U.S. Pat. No.2,268,755, issued to S. F. Li; and U.S. Pat. No. 1,635,602, issued to H.G. Gould et al have been designed for aiding the surgeon is applying asingle pretied length of suture material to a bleeder. Otherinstruments, such as that disclosed in U.S. Pat. No. 2,371,082 issued toF. Vistreich are designed to apply a single collar of resilient materialto a deep bleeder. However, these instruments, since they apply only oneligature at a time after which another preformed ligature must beaffixed to the instrument before it can then be applied to the nextbleeder, do not materially reduce the amount of time or effort requiredin a surgical procedure. Other more complex instruments, such asdisclosed in U.S. Pat. Nos. 2,898,915 and 2,898,916, issued to K.Kammer, have been devised for automatically tying a successive pluralityof ligatures from a spool of suture material. I disclosed a repeatingligature gun for applying a plurality of pretied or preformed ligatures(U.S. Pat. No. 3,687,138). However, these prior art instruments arecomplex, are difficult to load with the suture material, and, beingcomplicated, are hard to disassemble and sterilize. None of the aboveprior art instruments have come into general use.

In order to obviate some of the above problems in the prior art,hemostatic clips have come into widespread use in surgery in recentyears. In current surgical practice, these clips are used not only foroccluding blood vessels but also for application to other structuressuch as nerves; for example, in vagotomy. A number of efforts have beenmade to facilitate loading of the clips into the instrument. Thisgenerally is done one at a time by a scrub nurse who then hands theinstrument to the surgeon for application and receives the emptyinstrument back for reloading with another single clip. As the clips aresmall and difficult to handle, cartridges which hold the clips and thenaid in loading the clips one at a time into the instrument have beendeveloped. Since the clips are not firmly held in the instruments, theysometimes fall out during handling of the instrument by the scrub nurseand the surgeon prior to application.

What is needed is an instrument which will rapidly and repeatedly clampand ligate bleeders; an instrument that can be operated with one hand;an instrument which does not leave any excess material, such as cut endsin the incision; an instrument which may be reloaded by means of acartridge with a plurality of preformed ligatures repeatedly during anoperation; and an instrument which is easy to disassemble and sterilize.

It is also desirable that the instrument handle as much as possible inthe same manner as prior art surgical instruments such as towel clamps,hemostats, and clip appliers. Furthermore, it would be a highlydesirable feature of such an instrument if it were adapted to apply ahemostatic clip which has already been accepted in surgical practice andin particular approved by the Food and Drug Administration (FDA) forretention in the human body as the provision of any other material oreven shape of clip or preformed ligature may be occasioned with years oftests and delay before FDA approval may be secured.

OBJECTS OF THE INVENTION

It is therefore an object of the invention to improve the art ofsurgery.

Another object of the invention is to provide for rapid ligation of aplurality of bleeders.

Still another object of the invention is to provide preformed clips forfacilitating the above objects.

A further object of the invention is to provide an instrument forapplying a plurality of clips of the above character.

Another object of the invention is to provide an instrument of the abovecharacter which may be operated by one hand.

A further object of the invention is to provide an instrument of theabove character which leaves no excess material or cut ends on thesutures in the body which have to be removed by the surgeon.

Still another object of the invention is to provide an instrument of theabove character which is convenient to sterilize without disassembly.

Yet another object of the invention is to provide an instrument of theabove character which does not require lubrication.

Still another object of the invention is to provide an instrument of theabove character employing a replaceable cartridge or carrier for aplurality of preformed clips of the above character.

A further object of the invention is to provide a cartridge of the abovecharacter which is disposable.

A still further object of the invention is to provide an instrument ofthe above character which can affix clips to bleeders with varyingtension according to the size of the vessel and type of tissue in whichit occurs.

Another object of the present invention is to provide an automaticrepeating clip applying instrument which will obviate the need forreloading prior to each clip application, hold the clips securely duringhandling so they cannot fall out, and speed surgical procedures.

It is a further object of the invention to provide a repeatinginstrument which has substantially the same form as present single clipapplying instruments and which operates essentially the same as singleclip instruments do during clip application; that is, which crushes aclip flat between two jaws when two ring handles are squeezed togetherthus providing the same "feel" as hemostats and clip appliers of theprior art.

To facilitate reloading of the repeating instrument, it is also anobject of the present invention to provide a disposable cartridgecontaining a plurality of clips, which may be simply and quickly affixedto and removed from the instrument.

Still a further object is to provide an instrument with an elongated tiphaving delicate jaws to permit unobstructed visibility of the clipapplying jaws as the clip is applied to tissue even in deep andrestricted areas. To accomplish this, it is an object of the inventionto provide a small and streamlined cartridge which is located remotefrom the tip.

Another object of the invention is to provide an instrument of the abovecharacter which is adapted to apply hemostatic ligating clips which havealready been accepted in surgical practice and by the Food and DrugAdministration.

A further object of the invention is to provide an instrument of theabove character which is highly reliable and formed of very few movingparts.

Still another object of the invention is to provide an instrument,cartridge and clips of the above character which may be mass produced atlow cost, are convenient to use, and require little or no servicing.

Other objects of the invention will in part be obvious and will in partappear hereinafter.

The invention accordingly comprises articles of manufacture possessingthe features, properties and the relations of elements which will beexemplified in the articles hereinafter described, and apparatuscomprising the features of construction, combinations of elements andarrangements of parts which will be exemplified in the constructionshereinafter set forth. The scope of the invention is indicated in theclaims.

THE DRAWINGS

For a fuller understanding of the nature and objects of the invention,reference should be had to the following detailed description taken inconnection with the accompanying drawings in which:

FIG. 1. is a top perspective view of a repeating hemostatic clipapplying instrument and multi-clip cartridge therefor assembled andready for operation.

FIG. 2 is a top view of the instrument shown in FIG. 1 in partial crosssection along the plane 2--2 of FIG. 1.

FIG. 3 is an enlarged top view, partially cut away, of the instrumentshown in FIG. 1 with the cross section of FIG. 2 extended and theinstrument partially actuated to move a clip from the cartridge to theclip applying jaws.

FIG. 4 is an enlarged top view, partially in cross section, similar toFIG. 3 showing the instrument fully actuated to close the clip betweenthe jaws.

FIG. 5 is an enlarged cut away view showing a detail of the jaws.

FIG. 6 is a cross-sectional view, partially cut away, taken along theline 6--6 of FIG. 2.

FIG. 7 is an enlarged exploded perspective cut away view of the clipapplying jaws and a portion of the cartridge mount.

FIG. 8 is an exploded diagrammatic view showing the small number ofbasic parts of the instrument of FIG. 1.

FIG. 9 is an enlarged cross-sectional cut away view taken along theplane 9--9 of FIG. 2.

FIG. 10 is a top cross-sectional cut away view taken along the line10--10 of FIG. 9.

FIG. 11 is a cross-sectional view taken along the line 11--11 of FIG. 9.

FIG. 12 is an enlarged top perspective view of the cartridge of theinvention shown in FIG. 1.

FIG. 12A is an end plan view of the cartridge shown in FIG. 12.

FIG. 13 is an enlarged perspective bottom view similar to FIG. 12.

FIG. 14 is an enlarged perspective diagrammatic top view of the clipsand clip follower of the cartridge of FIG. 1.

FIG. 15 is a partial cross-sectional top view, partially cut away,similar to FIG. 2, of an alternative embodiment of the invention havinga different clip advancing mechanism.

FIG. 16 is a top view partially in cross-section and partially cut awaysimilar to FIG. 15 showing the alternative embodiment with the clipadvance mechanism fully advanced.

FIG. 17 is a partial cross-sectional view partially cut away taken alongthe line 17--17 of FIG. 15.

FIG. 18 is a top perspective view similar to FIG. 1, partially cut away,of an alternative embodiment of the invention having curved jaws forimproved handling and visibility.

FIG. 19 is a top plan view of another alternative embodiment of theinvention having a single pivot and a floating bell crank pusheractuating mechanism.

FIG. 20 is a top plan diagrammatic view of an alternative form of clipcartridge.

FIG. 21 is a top plan view of a U-shaped clip having a V-shapedconnecting section.

The same reference characters refer to the same elements throughout theseveral views of the drawings.

GENERAL DESCRIPTION

In general, the present invention is similar in function to existingsingle clip applying instruments such as disclosed in U.S. Pat. No.3,713,533 in that with one actuation of the instrument, one clip isapplied to tissue by being crushed thereabout by a pair of jaws. Theclips are preferably also of substantially the same material size andshape when closed about the tissue as the formed clips disclosed in thatpatent. The instrument of this invention is so designed that in itspreferred embodiment it is substantially similar in shape to presentsingle clip applying instruments which are, in fact, designed much likenumerous types of hemostats and other surgical clamps, having two ringhandles and a generally elongated form which permits controlled handlingand good visibility at the tip.

The present invention differs from single clip applying instruments inthat a disposable cartridge is provided which holds a plurality of clipsand feeds them to the instrument one at a time. Other instruments havebeen patented for repeatedly applying surgical clips or ligatures suchas disclosed in U.S. Pat. Nos. 2,277,139, 2,968,041, 3,082,426,3,844,289, 3,638,847, and my Patent No. 3,841,521. However, although theneed for a repeating hemostatic clip applying instrument has beenrecognized for decades, none is presently in the market or in clinicaluse.

Deficiencies in prior art repeating instruments which have led to theirnonuse in clinical practice may be categorized as: overly complexinstruments with a very large number of parts; instruments which obscurethe physicians' field of view; gun type instruments which meet greatresistance on the part of surgeons used to ring-handled plier typeinstruments; instruments with a great many small moving interfacesbetween parts which make them subject to frictional failure, extremelydifficult to sterilize without dissassembly, and extremely difficult todisassemble and re-assemble for good sterilization practice; lack ofsimple replaceable cartridges; operation which requires pulling oftissue into the instrument; and complex cartridge mechanisms which leadto prohibitive cartridge costs.

The present invention recognizes that optimal visibility to the tip,incorporation of an inexpensive multiple clip containing cartridge whichcan be rapidly changed, and completely automatic one hand operation,preferably with a ring handle configuration, are crucial if theinstrument is to be clinically useful.

A new principle unique to all clip applying instruments is employed. Adisposable cartridge, removably mounted on the instrument, holds aplurality of clips in alignment with a channel on the instrument. Theinstrument then removes the clips, one at a time, from the cartridge andfeeds them through the channel to the jaws for application to thetissue. This principle of having the cartridge feed the clips to aposition on the instrument remote from the jaws and then having theinstrument feed each clip to the jaws permits the cartridge to be placedremote from the jaws, out of the line of visibility. It also permits thesimplest possible construction of the jaws, that is, of only two pieces,which further aids visibility.

The instrument of this invention thus has a pair of clip applying jawswith a channel leading thereto from a remote position where a cartridgecontaining a plurality of clips may be removably affixed. It, inaddition, has a clip feed mechanism and appropriate sequencing andspring return means so that, in operation, when a pair of ring handlesare squeezed together, the forwardmost clip is removed from thecartridge, fed to the jaws and clamped about isssue positionedtherebetween, and, upon release, the instrument returns to a positionready to repeat.

The instrument is basically comprised of four main portions: (1) a firstpivoted member comprising a ring handle with a wide distal portionterminating in one jaw member; (2) a second pivotal member having a widedistal portion terminating in the other jaw member; (3) a clip pushingmechanism; and (4) an elongated ring handle. One of the distal portionsis provided with a channel for a pusher to push the hemostatic clips tothe jaws. This distal portion also has a cartridge receiving portion.The other distal portion acts as a cover for the channel. A linkage isprovided between the ring handles and the clip pushing mechanism forpushing the clip out of the cartridge, forward to the jaws and thenallowing the jaws to close. This is accomplished in two embodiments ofthe invention by providing a rotating bell crank on a proximal extensionof the pusher channel member.

The bell cranks each have a cam which is engaged by an extension on oneof the ring handles and is operated by an extension on the other ringhandle to rotate when the handles are first closed to operate the pushmember. The cam has a cut away portion into which the extension on theopposite ring handle then falls to allow the handle to close and closethe jaws.

In another embodiment of the invention, the bell crank is free floatingand is connected by its center pivot to one ring handle and at one ofits outer pivots to the other ring handle, and at the other outer pivotto a link connected to the pusher. This free floating bell cranklinkage, by its geometry, causes the pusher to be operated against theforce of a weak spring. Thereafter the ring handle to which no jaw isconnected, biassed by another spring, is able to come down against asurface of the jaw mechanism to which no ring handle is connected toclose the jaws.

In general the cartridge mechanism of the invention comprises means forholding a stack of generally U-shaped clips aligned perpendicular to theplane of the pusher channel, a spring to push the clips toward thepusher channel, a bottom stop for preventing the clips from falling outof the cartridge, interlocking mechanism for interlocking the cartridgewith the instrument, a clip follower between the stack of clips and thespring mechanism, and finger grips for ease of application and removalof the cartridge to or from the instrument. As used herein, U-shapedindicates a clip having two substantially parallel arms connected by abight of constant radius, by a V-shaped section, or by any variation ofthese.

The clips are preferably rectangular in cross section and provided witha knurled pattern on the inside surface to help retain tissue. Arectangular cross section having a height/width ratio of 2/1 isparticularly preferred to prevent the clips from twisting as they areclosed and to provide the closed clip with a square cross section. Theclip may be of any convenient size and constructed of any biomedicallyacceptable material. A particularly preferred clip is one formed oftantalum and having a uniform rectangular cross section of 0.015 in.wide by 0.030 in. high. The inside surface of the clip is preferablycoined in a diamond knurl pattern to increase the gripping power of theclip on the tissue.

SPECIFIC DESCRIPTION

More particularly, referring to FIG. 1, a repeating hemostatic clipapplying instrument according to the invention is generally indicated at42. It comprises a left and a right jaws 44 and 46 at the end of leftand right distal end portions 48 and 50.

Referring to FIGS. 1 and 8, left jaw 44 is mounted to the distal end 48of a left jaw actuating member generally indicated at 52 comprising theaforesaid distal end 48, pivot hole 54, handle shaft 56, handle ring 58,and sequencing stop extension 60. Distal end 48 is provided with acartridge clearance cut out 62 (see also FIGS. 7 and 9). A jaws returnspring 64 is attached to the handle shaft 56 by means of appropriaterivets, screws, or the like 66.

Still referring to FIGS. 1 and 8, particularly FIG. 8, the right jaw 46and right distal extension 50 are part of a single main body generallyindicated at 68. Main body 68 has a pivot hole 70, commonly pivoted topivot hole 54 on left jaws actuating member 52 around a pivot 72 shownin FIG. 1. The main body 68 has a channel formed therein by alternatingslots 74 in the bottom thereof and 76 in the top thereof which overlapto form a continuous channel which terminates at an elongated cut out 78for receiving the cartridge generally indicated at 80.

The pusher channel is extended as clip channel 82 on the bottom side ofthe distal end 50 of the main body 68 to the right jaw 46.

The main body 68 is also provided with stabilizing flanges 84, bellcrank pivot hole 86, a pusher actuating member stop 88, a pusheractuating member pivot 90 to which a pusher actuating member, generallyindicated at 92, is pivoted by means of a pivot hole 94 therein, and apivot 96 (FIG. 1).

Still referring to FIGS. 1 and 8, particularly FIG. 8, the pusheractuating member 92 comprises a handle shaft 96, a ring handle 98, and abell crank actuator extension 100 having a bell crank pivot slot 102therein. The pusher actuating member 92 is provided with a pusher returnspring 104 which is preferably less strong than the jaws return spring64.

Still referring to FIGS. 1 and 8, particularly FIG. 8, a clip pusher,generally indicated at 106, is preferably provided with a thin forwardportion 108 and thick rearward portion 110. It is connected by means ofpivot 112 to a pusher link 114, which in turn is connected by means of apivot 116 to a bell crank, generally indicated at 118. As best seen inFIG. 1, bell crank 118 is provided at one end with a bifurcated arm 122straddling a narrow portion of pusher link 114 and at its opposite endwith a bifurcated arm 124 straddling bell crank actuator extension 100.Pivot pin 126 is fixed in arm 124 and rides in bell crank pivot slot 102(FIG. 8).

Still referring to FIGS. 1 and 8, the bell crank 118 is provided with asequencing stop surface 128 on which sequencing stop extension 60 rides,a sequencing drop-off cut out 130 and a main pivot 132 pivoted to thebell crank pivot hole 86 by means of pivot 134 (FIG. 1) - sequencingstop surface 128 and cut out 130 forming a cam.

The main body 68 is relieved at 95 for rotation of bell crank 118 and at95' for rotation of the link 114 and rotation of bell crank 118 (FIGS. 1and 2).

Now referring to FIGS. 9 through 13, a plurality of U-shaped hemostaticclips, generally indicated at 136, are stacked vertically in clipchamber 170 of cartridge 80 formed by guide means 158, 160 and 166. Clipstack 136 is perpendicular to the plane of pusher 106 with lowermostclip 142 resting in the plane of pusher 106 on clip stop platform 162.Platform 162 cooperates with clip chamber guide means to form a rearwardaperture for receiving pusher 106 and a forward rectangular slot 169 forpassing clip 142 from the cartridge. Clip guide means 152 which alsofunctions as an interlocking mechanism for interlocking the cartridgewith the instrument, has a channel corresponding in width to the widthof the clips 136 and slot 169 for guiding and aligning clip 142 as it ispushed from the clip stack into clip channel 82 by pusher 106. Lowermostclip 142 resting on platform stop 162, forward slot 169 and the channelin clip guide 152, are all aligned with clip channel 82 extending tojaws 44 and 46 when cartridge 80 is mounted on instrument 42 as bestseen in FIG. 9.

In operation, with the cartridge 80 mounted to the instrument 42 asillustrated in FIGS. 1 through 4, the pusher 106 extends to just behindthe clips 136. The surgeon places the jaws 44-46 about tissues to beclipped. He then closes the two ring handles 58-98. First the pusheractuating member 92 moves about pivot 97 against pusher return spring104, this rotates the bell crank counter-clockwise pushing the pusher106 by means of pusher link 114 to cause the lowermost clip 142 (FIG. 9)in the clip stack 136 to be advanced through slot 169 and the channel ofclip guide means 152 into channel 82 to between the jaws 44 and 46 asshown in FIG. 3. Since the jaws 44-46 surround tissue, the clip 142 ispushed around the tissue and remains in the jaws. As shown in FIGS. 5and 7, the jaws 44-46 are preferably provided with clip slots 138extending from the clip channel 82 and opening at a two degree angletherefrom. This angle assures that the jaws will be parallel whenclosed. Small detents (not shown) may be disposed at the forwardmost endof the clip slots 138 (FIG. 7) to stop distal motion of the clip.

During the above action, and referring to FIG. 3, the sequencing stopextension 60 has been riding on the sequencing stop surface 128 of thebell crank 118. However, once the pusher 106 has advanced to itsfarthest position (at this position pusher actuating member handle shaft96 contorts stop 88), the sequencing stop extension 60 drops into thesequencing drop cutoff 130 on the bell crank 118. This allows the leftjaw actuating member 52 to rotate about pivot pin 72 thereby bringingthe left jaw 44 against the right jaw 46, to close the clip 142 all asshown in FIG. 4. The sequencing drop cutoff 130 positively preventsreturn of the pusher 106 so that the clip is positively locked betweentissue, jaws 44-46, and the distal end of the pusher 106 until the jawsare closed.

When the surgeon now releases the pressure on the handle shafts 56 and96 of the left jaw actuating member 52 and pusher actuating member 92,the jaw return spring 64 first rotates left jaw actuating member 52about pivot pin 72 under action of the jaws return spring 64 until itcomes against the head of adjustment screw 144 mounted to the main body68. Cam surface 130, being released by stop extension 60, rotates aboutpivot 134 and pusher actuating member 92, under the action of pusherreturn spring 104, rotates about pivot 97 returning the instrument toits rest position shown in FIG. 2.

The clips may also be mounted in the cartridge 80 with their open endsslightly resiliently pressed together so that they tend to widen whenreleased. This allows them to widen when they reach the jaws 44-46 andto be resiliently retained therein. Alternatively, the clearance betweenthe jaws may be made smaller than the channel through which the clipsare pushed, so that they are resiliently squeezed down when they reachthe jaws to be retained therein. The clip slots may also be providedwith transversely oriented serrations for retaining the clips therein,in the manner disclosed in U.S. Pat. No. 3,713,533.

Again, referring to FIGS. 9 through 13, the cartridge 80 comprises amain body portion 146, preferably of transparent plastic material forlow cost manufacture and to allow the user to see the number of clips136 remaining in the stack or magazine and a leaf spring 148 mountedthereto, by suitable attachment means, for example, a screw 150. Thoseskilled in the art will understand that spring 148 may be attached bymeans of a heat sealed plastic rivet or might even be integrally moldedwith the body 146 if a suitable plastic were employed. The cartridge 80fits snugly into cartridge cut out 78 in right jaw extension 50. Theforward end of the cartridge body 146 is provided with a forward clipguide means and retention tongue 152. Since the cartridge closely fitsinto the cut out 78, no other retention means is required. However, adetent and recess may be provided at the rear extension 154 of thecartridge body 146 and the rear end 156 of the cut out 78, or on othersuitable parts of the cartridge and adjacent parts of the instrument.

The cartridge body is provided with guide surfaces 158 and 160 forguiding the clip magazine or stack 136 and at the bottom thereof with aclip platform stop 162, which fits into the cartridge clearance cut out62 in the distal left jaw extension 48. The end of the spring 164preferably extends through a cut out 166 to provide a visual indicationof the number of clips remaining in the stack 136.

Spring pressure and friction prevents bottom clip 142 from moving eitherforward or rearward when the cartridge is out of the instrument. A clipfollower 172 is provided for applying the force of the spring 148against the clip stack 136 in an even manner. To this end, the clipfollower 172 is provided with a clip follower fulcrum ridge 174 within aclip follower spring guide slot generally indicated at 176. Since theclip follower fulcrum ridge 174 is at the middle of the clip follower172, the force is applied evenly to the clip stack 136 and the clipsstack cannot rock out of alignment with the clip channel extension 82.

An alternative form sequencing mechanism is employed in the alternativeembodiment illustrated in FIGS. 15, 16, and 17. Here, the bell crank,generally indicated at 180, is provided with a sequencing stop extensionaccepting slot 182 for receiving an elongated sequencing stop extension184 mounted to the handle shaft 56 of the left jaw actuating membergenerally indicated at 52. The pusher slide channel 186 is formed in twopieces, 188 and 190, joined together by a plurality of fasteners 192. Asingle spring 194 is employed which is mounted to handle 56 by rivets orscrews 196 and acts between handle 56 and bell crank actuator extension100 by means of ears 198 acting on extended pivot pin 200.

Referring to FIG. 17 in this embodiment of the invention, the bell crank180 is provided with a narrow arm 202 which fits into a slot 204 formedin the bell crank actuator extension 100.

In another alternative form of the invention, illustrated in FIG. 18,the thin forward portion 108 of the clip pusher 106 (not shown) is madeflexible and the distal extensions 50 and 48 are curved for bettervisibility of the tip for use by surgeons who are used to curved oroffset hemostatic instruments. The cartridge 80 may be, but need not be,conformed to this curvature which may be restricted to the portion ofthe instrument between the jaws 44 and 46 and the rearward end of thecartridge 80.

Now referring to FIG. 8, those skilled in the art will understand, uponreflection, that the two pivot points of pivot holes 54 and 70 and pivotholes 90 and 94 respectively, could be combined into common axis. Thatis, pivot hole 70 could be eliminated and pivot hole 54 moved down untilit was in line with pivot holes 90 and 94 when the instrument wasassembled. Furthermore, the cartridge cut out 50 and main body 68 couldbe formed as part of the left jaws actuating member in which case theright jaws actuating member would comprise only the right jaw 46, thedistal extension 50, the pivot hole 90, and the pusher actuating memberstop 88, which also acts as the right jaws actuating member whencontacted by the handle shaft 96 of the pusher actuating member 92.

Now referring to FIG. 19, a single pivot instrument is generallyindicated at 220. It comprises a main body 222 having a jaws extension224 terminating in lower jaw 226. The upper finger loop extension 228 isintegral with the main body 222 and terminates in upper finger loop 230.Lower finger loop extension 232 is pivoted to the main body at pivot 234and terminates in lower finger loop 236. Upper jaw 238 is mounted to anarm also pivoted at pivot 234 and terminating at an asymmetricalT-shaped extension generally indicated at 240. The lowermost extension242 is contacted with lower finger loop extension 232 when the twofinger loops 230 and 236 are brought together and this causes theT-shape extension 240 and the upper jaw 238 to pivot about pivot 234against the action of a spring 244 mounted at one end to finger loopextension 228 and engaging the uppermost portion 246 of the T-shapedextension 240.

The pusher mechanism is mounted in the main body 222 and a portion ofthe pusher channel 248 may be seen. The distal end of the pusher 250 ispivoted at pivot 252 to link 254. Link 254 is pivoted at pivot 256 tofloating bell crank 258 which is pivoted at pivot 260 and connected atits other end at pivot 262 to lowermost finger loop extension 232. Pivot260 is connected to link 264 which in turn is connected at its other endat pivot 266 to spring 265 which may be integral with spring 244 bothbeing mounted to uppermost finger loop extension 228. Travel of spring265 is preferably limited by stop 268 integrally formed with uppermostfinger loop extension 228.

When the two finger loops 230 and 236 are brought together pivot 260moves to position 260' and the linkages and other pivots move to thepositions shown by the dotted lines and circles connected to point 260'.This causes the pusher to move fully forward pushing the clip from thecartridge 269 forward in between the jaws 226 and 238. As the front endof finger loops 230 and 236 are brought closer together, pivot 266 movesto point 266' and lowermost finger loop extension 232 moves to position232' shown by dotted lines thus engaging the T-extension 240 and closingthe uppermost jaw 238 against the lower jaw 226.

Now referring to FIG. 20, an alternative form of clip cartridge 270having clipstack 272 therein may be provided with an internal clip legor with supporting flanges 274 to prevent the clips 272 from bendinginward within the cartridge 270. It will be understood that the walls ofthe cartridge 276 and 278 which engage the back bight 280 of theclipstack 272 need not continue all the way around the clips but merelyneed to engage the back of the clips to prevent them from movingbackward in the stack.

In FIG. 21 there is shown a preferred form of U-shaped clip 300 havingstraight legs 302 and a V-shaped bight 304. The apex 306 of the bight304 provides a crease which insures that the clip will close at theapex. This provides smoother operation of the instrument and insuresthat the legs 302, when closed on a bleeder, are of the same length.Otherwise, clip 300 is the same as those previously described.

Referring again to FIGS. 1 through 4, those skilled in the art will alsounderstand that the pusher return spring 104 acting between the mainbody 68 and the pusher actuating member 92, could be located anywhere inthe operating chain between the bell crank actuator extension, the bellcrank 118, the pusher link 114 or the clip pusher 106, and the main body68. All that is required is that a force cause the pusher member 106 toreturn to its normal position. This will also cause the entire mechanismincluding the pusher actuating member 92 to return to its normal restposition. Thus a compression spring may be located within the main bodyoperating directly on the pusher 106 or the link pin 112 or a coilspring may operate between the main body 68 and the bell crank 118, orbetween the bell crank and the pusher link, or between the bell crankand the bell actuator extension. Similarly, the jaws return spring 64may be replaced by any spring providing ultimately a rotational forcebetween the left jaw actuating member 52 and the right jaw 46. Thus,compression springs may be mounted between the main body 68 and thehandle shaft 56 or between the distal extension 48 and 50, or a coilspring may act at the pivot hole or at the pivot 72 (FIG. 1). Similarly,a coil spring acting at the pivot 97, between the main body 68 and thepusher actuating member 92 could replace the pusher return spring 104.

Those skilled in the art will also understand that many differentsequencing mechanisms could be employed, which, upon bringing the tworing handles 58 and 98 together, would cause the pusher 106 to advancethe lowermost clip 142, and then the jaws 44 and 46 to close, closingthe clip. One such instrument employing a free floating bell crank isillustrated in FIG. 19. This instrument also employs a single pivot. Nowreferring to FIG. 19, many other sequencing mechanisms will come tomind, for example, a rack and gear mechanism for advancing the pusher.However, it will be noted by those skilled in the art that I haveprovided simple mechanisms employing only rotary contacts for lowfriction and smooth operation, which also provide very long pushertravel for relatively small closure travel between the ring handles.

I have thus provided repeating clip applying instruments and cartridgestherefor, which may be employed during an operation to apply any numberof hemostatic clips by merely changing pre-sterilized cartridgescontaining a plurality of the clips.

It will thus be seen that the objects set forth above, among those madeapparent from the preceding description, are efficiently attained andsince certain changes may be made in the above articles andconstructions without departing from the scope of the invention, it isintended that all matter contained in the above description or shown inthe accompanying drawings shall be interpreted as illustrative and notin a limiting sense.

For example, all of the clips in the cartridge need not be stacked as Ihave shown in FIG. 9. All that is necessary is that the bottom most clip142 be presented at the end of the pusher and the beginning of the clipchannel leading to the jaws. Thus, the clips might be mountedhorizontally in a plane above the pusher, all biased by a springforward, and another spring would be provided for biasing theforwardmost clip downward against the clip platform stop so that itwould be in position at the forward end of the pusher for being pushedinto the clip channel. Many other variations will readily come to mindupon reflection.

Moreover, it will be seen that I have provided a repeating hemostaticclip applying instrument involving very few parts, which is simple tooperate and use, convenient to sterilize and surprisingly provides thisin an instrument which handles in the manner in which surgeons havedesired for many years. I have achieved this surprising result by acunning choice of elements that synergistically work together.

It is to be understood that the following claims are intended to coverall of the generic and specific features of the invention hereindescribed, and all statements of the scope of the invention which, as amatter of language, might be said to fall therebetween.

Having described my invention, what I claim as new and desire to secureby Letters Patent is:
 1. A hemostatic clip cartridge adapted to beremovably mounted on a repeating hemostatic clip applying instrument,said cartridge comprising:A. a plurality of generally U-shaped planarhemostatic clips in vertical alignment forming a U-shaped stack, saidclips adapted to be crushed about tissue one at a time by theinstrument; B. stack-guide means for confining and guiding said U-shapedstack for motion along the vertical axis of said stack; C. spring meansfor biasing said stack downward; D. stop means at the bottom of saidstack-guide means for preventing said stack from further downwardmotion, said stop means cooperating with said stack-guide means to forma rearward aperture for receiving a clip pusher member of the instrumentand a forward rectangular slot for passing a single clip; E. clip-guidemeans comprising a channel member extending horizontally from saidforward slot, the width of said forward slot corresponding to the widthof the channel in said clip-guide means; and, F. quick releaseinterlocking means adapted to interlock with the instrument for quicklymounting and dismounting the cartridge on the instrument so that aplurality of cartridges can be used in a single surgicalprocedure;wherein said clip pusher member of the instrument upon whichthe cartridge is mounted may push the lowermost clip of said stackthrough said forward slot and into said clip-guide means.
 2. Thecartridge of claim 1 wherein said planar clips are of substantiallyuniform rectangular planar cross section.
 3. The cartridge of claim 2wherein the ratio of height to width of the rectangular cross section ofeach clip is approximately 2:1.
 4. The cartridge of claim 1 wherein saidU-shaped planar clips comprise two substantially parallel arms connectedby a bight of constant radius.
 5. The cartridge of claim 1 wherein saidU-shaped planar clips comprise two substantially parallel arms connectedby a V-shaped section.
 6. The cartridge of claim 1 wherein the innersurface of said U-shaped clips is roughened relative to the outersuface.
 7. The cartridge of claim 6 wherein the said inner surface ofsaid clips is coined in a diamond shaped, knurled pattern.
 8. Thecartridge of claim 1 wherein said stop means comprises a plate acrossthe bottom of said guide means.
 9. The cartridge of claim 1 wherein thechannel member of said clip-guide means has an open bottom.
 10. Ahemostatic clip cartridge adapted to be removably mounted on a repeatinghemostatic clip applying instrument, said cartridge comprising:A. aplurality of generally U-shaped planar hemostatic clips in verticalalignment forming a U-shaped stack, said clips adapted to be crushedabout tissue one at a time by the instrument; B. a clip follower bearingon the uppermost clip in said stack and having an outside dimensioncorresponding to the dimensions of said U-shaped stack; C. stack-guidemeans for confining and guiding said clip follower and U-shaped stackfor motion along the vertical axis of said stack; D. spring means forbiasing said clip follower and said stack downward; E. stop means at thebottom of said stack-guide means for preventing said stack from furtherdownward motion, said stop means cooperating with said stack-guide meansto from a rearward aperture for receiving a clip pusher member of theinstrument and a forward rectangular slot for passing a single clip; F.clip-guide means comprising a channel member extending horizontally fromsaid forward slot, the width of said forward slot corresponding to thewidth of the channel in said clip-guide means; and G. quick releaseinterlocking means adapted to interlock with the instrument for quicklymounting and dismounting the cartridge on the instrument so that aplurality of cartridges can be used in a single surgicalprocedure;whereby said clip pusher member of the instrument upon whichthe cartridge is mounted may push the lowermost clip of said stackthrough said forward slot and into said clip-guide means.
 11. Thecartridge of claim 10 wherein said clip follower has a planar surfacebearing on the uppermost clip of said stack and a fulcrum contactingsaid spring means.
 12. The cartridge of claim 11 wherein said fulcrumcomprises a ridge extending across the center of said clip follower. 13.The cartridge of claim 10 andG. an elongated cartridge body in whichsaid stop means, said stack-guide means, said rearward aperture and saidforward rectangular slot are formed; andwherein said spring comprises anelongated spring attached to the rear of said cartridge body.
 14. A clipsupply cartridge removably mountable upon a repeating clip applyingsurgical instrument having an axial clip channel and a narrow elongatedclip pusher for pushing a clip through said channel to a pair of jaws,said instrument adapted to permit removal of a plurality of clips fromthe cartridge by the instrument one at a time with each actuation of theinstrument, said cartridge comprising:A. a chamber adapted to confine astack of generally U-shaped clips and permit motion of the stack onlyalong its axis, having guide means parallel to the stack of clips, saidclips adapted to be crushed about tissue one at a time by theinstrument; B. stop means at one end of the chamber to prevent the clipsfrom escaping from the chamber along the axis of the chamber; C. springmeans urging an entire stack of clips contained within said chamberagainst said stop means; D. two openings in the chamber adjacent to thestop means permitting only the one clip in contact with the stop meansto pass through by moving in a direction parallel to the arms of theU-shaped clip in a plane at substantially right angles to the axis ofthe clip stack, said openings providing a passageway through which thenarrow elongated clip pusher of the instrument may move to force a clipout of the cartridge and into a channel in the instrument; E. means foraligning and retaining the cartridge on the instrument such that theclip in the cartridge in contact with the stop means is aligned with thechannel of the instrument and as the pusher forces the clip all the wayto the jaws of the instrument the remaining clips in the cartridge areblocked by the pusher from entering the position adjacent to the stopmeans; and F. quick release interlocking means adapted to interlock withthe instrument for quickly mounting and dismounting the cartridge on theinstrument so that a plurality of cartridges can be used in a singlesurgical procedure.
 15. The cartridge defined in claim 14 wherein saidalignment and retention means comprises a tongue extending from thevicinity of the opening from which clips are ejected one at a time, saidtongue having a slot through which the clips and the pusher of theinstrument may pass and being adapted to slip snugly beneath an undercuton the instrument.
 16. The cartridge defined in claim 14 wherein saidspring means comprises a leaf spring.
 17. The cartridge defined in claim16 andF. a clip follower for use within said clip chamber adapted to beplaced between the stack of clips and said leaf spring acting on thestack of clips, said clip follower having a shape in cross sectionsubstantially the same as the cross section of said clip chamber andhaving a ridge forming a fulcrum upon which said leaf spring rides so asto distribute the force uniformly to the clip stack throughout the rangeof motion of said leaf spring.
 18. A clip follower as defined in claim17 having a verticle dimension large enough that it cannot be ejectedfrom the opening in the cartridge that the clips are ejected from andserving to lock the instrument when the cartridge is empty.
 19. Thecartridge defined in claim 14 wherein said chamber has means forretaining each arm of the clips from two sides.
 20. The cartridgedefined in claim 14 having two finger grips which project beyond theedges of the instrument when the cartridge is mounted thereupon tofacilitate mounting the cartridge to and removing the cartridge from theinstrument.
 21. A hemostatic clip magazine adapted to be removablymounted on a repeating hemostatic clip applying instrument, saidcartridge comprising a plurality of identical planar hemostatic clips ofsubstantially uniform rectangular planar cross-section, said clipsadapted to be crushed flat about tissue one at a time by the instrument,formed of elongated material of rectangular cross-section into agenerally U-shape, and comprising two parallel straight portionsconnected by a bight, the dimensions of said rectangular cross-sectionthroughout a substantial portion of said straight portions beingsubstantially two to one with the shorter dimension take parallel to theplane formed by said straight portions, a diamond shaped knurled patterncoined in the entire inner surface of said U-shaped clips, and saidU-shaped clips being stacked in vertical alignment to form a U-shapedstack and quick release interlocking means adapted to interlock with theinstrument for quickly mounting and dismounting the cartridge on theinstrument so that a plurality of cartridges can be used in a singlesurgical procedure.
 22. The hemostatic clip magazine defined in claim 21wherein said bight portion is of substantially constant radius.
 23. Thecartridge of claim 1 wherein said clips are adapted to be crushed flatabout tissue.
 24. A hemostatic clip cartridge comprising:a. a pluralityof generally U-shaped planar hemostatic clips in vertical alignmentforming a U-shaped stack, said clips adapted to be crushed flat abouttissue one at a time by the instrument; b. stack-guide means forconfining and guiding said U-shaped stack for motion along the verticalaxis of said stack; c. spring means for biasing said stack downward; d.stop means at the bottom of said stack-guide means for preventing saidstack from further downward motion, said stop means cooperating withsaid stack-guide means to form a rearward aperture for receiving a clippusher member of the instrument and a forward rectangular slot forpassing a single clip; e. clip-guide means comprising a channel memberextending horizontally from said forward slot, the width of said forwardslot corresponding to the width of the channel in said clip-guidemeans;whereby said clip pusher member may push the lowermost clip ofsaid stack through said forward slot and into said clip-guide means. 25.The cartridge defined in claim 14 andF. a clip follower for use withinsaid clip chamber adapted to be placed between the stack of clips andsaid spring acting on the stack of clips, said clip follower having ashape in cross section substantially the same as the cross section ofsaid clip chamber and having a ridge forming a fulcrum upon which saidspring rides so as to distribute the force uniformly to the clip stackthroughout the range of motion of said spring.
 26. The cartridge definedin claim 25 having an elongated opening through which a free end of saidspring projects beyond said chamber without permitting escape of theclips, such that the position of the free end of said spring is visiblewhen the cartridge is mounted upon the instrument and its positionprovides an estimate of the number of clips remaining in the cartridge.